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Inspection Summary

Overall summary & rating


Updated 12 December 2019

We carried out an announced comprehensive inspection at Hawthorn Drive Surgery on 18 November 2019 to check that improvements identified at the October 2018 inspection had been made and to re-rate the practice.

The practice was previously inspected on 14 November 2016 and was rated as inadequate for providing safe, effective and well led services, requires improvement for providing caring services and good for providing responsive services. Overall the practice was rated as inadequate. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 13 December 2016 for regulation 17 (good governance). They were also given a requirement notice for regulation 12, safe care and treatment. The practice was placed into special measures for six months.

A focussed inspection was undertaken on the 16 February 2017, to check on improvements detailed in the warning notice issued on 13 December 2016, following the inspection on 14 November 2016. The practice had complied with the warning notice. A comprehensive inspection was undertaken on 17 July 2017. The practice was rated good overall and good for all domains with the exception of effective, which was rated requires improvement. The practice was taken out of special measures.

The practice was inspected on 9 October 2018 to check that improvements had been sustained because the practice had gone from being in special measures to being rated good overall. The practice was rated as requires improvement overall and for safe and effective services, with requires improvement for the population groups people with long term conditions, people experiencing poor mental health and for people whose circumstances may make them vulnerable. The full inspection reports on the November 2016, February 2017, July 2017 and October 2018 inspections can be found by selecting the 'all reports' link for Hawthorn Drive Surgery on our website at .

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We found that:

  • Improvements had been made since our previous inspection; staff had completed training deemed mandatory, recruitment checks were in line with the practice’s recruitment policy, all staff had a Disclosure and Barring Service (DBS) check every three years in line with the provider’s policy and the professional registration of staff was checked at recruitment and annually in line with the provider’s policy.
  • An overdue hard wiring electrical check had been completed. Some improvements had been made to infection prevention and control; all staff had completed training and most audits demonstrated improvement in patient outcomes.
  • Patients received effective care and treatment that met their needs. Improvements had been made to patient outcomes for diabetes, chronic obstructive pulmonary disease, mental health and the review of patients identified as being frail, those with a new cancer diagnosis and those with palliative care needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

We saw one example of outstanding practice:

The practice employed a mental health nurse, emergency care practitioner and pharmacist, who ran an integrated clinic once a week. They met together with patients with complex needs for approximately one hour per patient, to plan and review their care and treatment. This work included the review of patients prescribed multiple medicines, which included opioid medicines. The clinic aimed to reduce reliance on these medicines, whilst ensuring other appropriate support was in place. This was agreed in partnership with the patient. This work was overseen by a GP and this high intensity work was in place for approximately 15 patients at a time.

The areas where the provider should make improvements are:

  • Continue to monitor and improve the uptake of cervical screening for eligible women and reviews for patients newly diagnosed with cancer.
  • Continue work to improve outcomes for patients with chronic obstructive pulmonary disease and diabetes.
  • Continue work to improve the management of infection prevention and control in relation to the documentation of clinical room cleaning.
  • Embed the newly established system to ensure the follow up of patients referred for suspected cancer.
  • Continue work to identify and support carers.
  • Document the approval process of all policies and procedures.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGPChief Inspector of General Practice

Inspection areas










Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable